Coronary Anomalies. Hany Abdel Shakour; M.Sc. Cardiology Assistant lecturer, Mansoura University

Transcription

1 Coronary Anomalies Hany Abdel Shakour; M.Sc. Cardiology Assistant lecturer, Mansoura University

2 Causes of SCD Over 35 yrs. of age Coronary Heart Disease Under 35 yrs. Cardiomyopathies Congenital Heart Disease Structurally Normal Heart (ion channel disorders, conduction disease) = SADS Anomalous coronaries (abnormal anatomical position of coronary blood vessels) Myocarditis (infection or inflammation of heart muscle)

3 coronary anomalies 25% AV stenosis 5% Myocarditis 4% DCM 3% ARVC 3% Myocardial Scarring 3% MVP 2% Atherosclerotic CAD 2% LQTs 0.5 0% Congenital HD 2% Sarcoidosis 1% Sickle cell Trait 1% Unexplained Cardiac Mass 10% HCM 37% Normal heart 2%

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5 Left Main or left coronary artery (LCA) Left anterior descending (LAD) diagonal branches (D1, D2) septal branches Circumflex (Cx) Marginal branches (M1,M2) Right coronary artery Acute marginal branch (AM) AV node branch Posterior descending artery (PDA)

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9 The LCA divides almost immediately into the circumflex artery (Cx) and left anterior descending artery (LAD). On the left an axial CTimage. The LCA travels between the right ventricle outflow tract anteriorly and the left atrium posteriorly and divides into LAD and Cx.

10 In 15% of cases a third branch arises in between the LAD and the LCx, known as the ramus intermedius or intermediate branch. This intermediate branch behaves as a diagonal branch of the LCx.

11 The LAD travels in the anterior interventricular groove and continues up to the apex of the heart. The LAD supplies the anterior part of the septum with septal branches and the anterior wall of the left ventricle with diagonal branches. The LAD supplies most of the left ventricle and also the AV-bundle.

12 The diagonal branches come off the LAD and run laterally to supply the antero-lateral wall of the left ventricle. The first diagonal branch serves as the boundary between the proximal and mid portion of the LAD (2). There can be one or more diagonal branches: D1, D2, etc.

13 The LCx lies in the left AV groove supplies the vessels of the lateral wall of the left ventricle. Obtuse marginal (OM1, OM2). 10% of patients have a left dominant circulation in which the LCx also supplies the posterior descending artery (PDA).

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15 In 50-60% the first branch of the RCA -Rt conus branch. In 36%- Directly from aorta

16 Also known as ARTERIA CONI ARTERIOSI, THIRD CORONARY. Anastomoses with a similar left coronary branch around pulmonary trunk ANNULUS OF VIEUSSENS

17 In 60% a sinus node artery arises as second branch of the RCA. The RCA continues in the AV groove posteriorly and gives off a branch to the AV node. In 65% of cases -right dominant circulation. The PDA supplies the inferior wall of the left ventricle and inferior part of the septum.

18 The large acute marginal (AM)or RV branch supplies the lateral wall of the right ventricle.

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20 Definetions

21 The definition of a coronary artery should be made without taking into account of its origin and proximal course but focusing on its intermediate and distal segments and/or its dependent micro vascular bed

22 CORONARY ARTERY Left anterior descending (LAD) Circumflex (Cx) MINIMALLY REQUIRED FEATURES Location: the anterior interventricular sulcus Subepicardial position (but not infrequently intramyocardial) Provides septal branches and follows the direction of the septum. Accompanied by a conspicuous venous branch (greater cardiac vein) Location: the left side of the coronary sulcus Subepicardial position Provides at least one marginal branch Right coronary artery (RCA) Location: the right side of the coronary sulcus Subepicardial position Provides at least the right ("acute") marginal branch

23 LEVEL VARIABLES 1.Ostium Number of ostia Location Size Angle of origination Shape (e.g. slit-like; membrane) The variable features of the coronary arteries 2. Size Small size 3. Proximal course Especially intramural tract Consider angle of origin 4. Mid-course Intraseptal tract or looping 5. Termination Fistula

24 Coronary anomalies of clinical and surgical relevance anomalous pulmonary origins of the coronaries(apoc); anomalous aortic origins of the coronaries (AAOC); congenital atresia of the left main (CALM) coronary aterio-venous fistulas (CAVF); coronary bridging (myocardial bridging); coronary aneurysms (CAn); coronary stenosis

25 ANOMALOUS PULMONARY ORIGIN OF THE CORONARY ARTERIES APOC "Major anomalies" ALCAPA severe Origin form Pulmonary sinus: 1, 2 or NF ARCAPA severe, rare -do- ACxPA Severe, rare -do ARCLCPA Severe, rare -do-

26 Left Coronary Arising From PA Bland-White-Garland Syndrome Blood flows from the RCA via collaterals to the left coronary artery, and then into the pulmonary artery.

27 ALCAPA ALCAPA results in the left ventricular myocardium being perfused by relatively desaturated blood under low pressure, leading to myocardial ischemia L-R SHUNT

28 ANOMALOUS AORTIC ORIGIN OF THE CORONARIES AAOC "Minor anomalies" LMCA from sinus1 RCA from sinus 2 LAD from sinus 1 LAD from RCA Cx from sinus 1 Cx from RCA Single coronary artery Inverted coronary arteries Other 1/3 of all coronary anomalies

29 Left Main Arising from Right Coronary Sinus Subtypes: Anterior free-wall course Retro-aortic course Septal course Inter-arterial- incidence 1:12,500 [Accounts for 60% of anomalous left main from right coronary sinus (2.8% overall coronary anomalies). Recognized association with ischemic symptoms and sudden death >50%]

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31 Anomalous RCA Takeoff From Left Coronary Sinus The most common, potentially serious coronary anomaly, accounting for 8.1% of serious coronary anomalies (25% incidence of sudden cardiac death).

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33 Congenital atresia of the left main coronary artery (CALM)

34 INTRAMYOCARDIAL COURSE Bridging (MYOCARDIAL BRIDGING) LAD LCx RCA Multiple Other atypical / rare Symptomatic or asymptomatic may require surgery

35 Myocardial Bridging Tunneled LAD Autopsy: ~30%, Angiographically: <5% Prevalent in HCM patients Segment proximal to bridge frequently shows atherosclerotic plaque (tunnel spared) Symptomatic patients may be treated with β-blocker or CCB Myotomy, CABG, and stenting in refractory cases

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37 CAVF "Major anomalies" CORONARY ARTERIO-VENOUS FISTULAS RCA to RV LAD to RA RCA, LAD to LV LCx to PA Diag to CS OM to SVC congenital / acquired single / multiple associated with: TOF ASD, VSD, PDA Pulm. atresia + intact septum

38 CORONARY ANEURYSMS CAn Ø > 1.5 x diameter of adjacent normal coronary artery RCA Cx and LAD Cx and RCA LAD and RCA Cx, LAD and RCA Cx and LAD Cx and RCA LAD and RCA Cx, LAD and RCA Cx LAD RCA Cx LAD Type I (diffuse, 2-3 vessels) Type II (diffuse in 1 vessel + Localized in other) Type III (diffuse in 1 vessel) Type IV (localized in 1 vessel) 88% in males Congenital (types I-IV) Acquired: -atherosclerotic; - Kawasaki, Marfan, Ehlers-Danlos, Takayasu - other systemic diseases, polyarteritis, scleroderma - infectious (incl. syphilis) - traumatic Aneurysm +/- stenosis

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